When it comes to cybersecurity compliance, words have specific meaning and it is important to get those terms correct. In reality, these cybersecurity documentation terms have quite different implications and those differences should be kept in mind since the use of improper terminology has cascading effects that can negatively impact the internal controls of an organization.
Cybersecurity, IT professionals, privacy and legal professionals routinely abuse the terms “policy” and “standard” as if these words were synonymous, when they are not! ComplianceForge compiled the information on this page to help get everyone on the same sheet of music, since documentation terminology is important as these words have specific meanings as they pertain to cybersecurity and privacy requirements.
Cybersecurity & data protection documentation needs to usable – it cannot just exist in isolation. This means the documentation needs to be written clearly, concisely and in a business-context language that users can understand. By doing so, users will be able to find the information they are looking for and that will lead to cybersecurity and privacy "best practices" being implemented throughout your organization. Additionally, having clearly-written and concise documentation can be “half the battle” when preparing for an audit, since it shows that effort went into the program and key requirements can be easily found.
A common question is “What is the difference between a policy vs a standard?”
In simple terms, a policy is a high-level statement of management intent that formally establishes requirements to guide decisions and achieve rational outcomes. A policy is intended to come from the CEO or board of directors that has strategic implications. However, a standard is a formally-established requirement in regard to a process, action or configuration that is meant to be an objective, quantifiable expectation to be met (e.g., 8 character password, change passwords every 90 days, etc.).
In reality, no one should ever ask for an exception to a policy. Exceptions should only be for standards when there is a legitimate business reason or technical limitation that precludes a standard from being followed (e.g., vulnerability scanning exception for a "fragile" application that breaks when scanned by the default scanning profile). It is important that if a standard is granted an exception, there should be a compensating control placed to reduce that increased risk from the lack of the required standard (e.g., segment off the application that cannot be scanned for vulnerabilities).
If you visualize these concepts, you can see the hierarchical nature of these documentation components, where policies are the foundation that everything builds upon:
All too often, documentation is not scoped properly, and this leads to the governance function being more of an obstacle as compared to an asset. A multiple-page “policy” document that blends high-level security concepts (e.g., policies), configuration requirements (e.g., standards), and work assignments (e.g., procedures) is an example of poor governance documentation that leads to confusion and inefficiencies across technology, cybersecurity, and privacy operations. Several reasons why this form of documentation is considered poorly-architected documentation include:
Human nature is always the mortal enemy of unclear documentation, as people will not take the time to read it. An ignorant or ill-informed workforce entirely defeats the premise of having the documentation in the first place.
If the goal is to be “audit ready” with documentation, having excessively-wordy documentation is misguided. Excessive prose that explains concepts ad nauseum in paragraph after paragraph makes it very hard to understand the exact requirements, and that can lead to gaps in compliance.
What Right Looks Like
In the context of good cybersecurity documentation, components are hierarchical and build on each other to build a strong governance structure that utilizes an integrated approach to managing requirements. Well-designed documentation is generally comprised of six (6) main parts:
Policies establish management’s intent;
Control Objectives identify leading practices (mapped to requirements from laws, regulations and frameworks);
Standards provide quantifiable requirements;
Controls identify desired conditions that are expected to be met (requirements from laws, regulations and frameworks);
Procedures / Control Activities establish how tasks are performed to meet the requirements established in standards and to meet controls; and
Guidelines are recommended, but not mandatory.
Understanding Basic Cybersecurity & Data Protection Documentation Components
Since words have meanings, it is important to provide examples from industry-recognized sources for the proper use of these terms that make up cybersecurity & privacy documentation:
Policies are high-level statements of management intent from an organization’s executive leadership that are designed to influence decisions and guide the organization to achieve the desired outcomes. Policies are enforced by standards and further implemented by procedures to establish actionable and accountable requirements. Policies are a business decision, not a technical one. Technology determines how policies are implemented. Policies usually exist to satisfy an external requirement (e.g., law, regulation and/or contract).
A document that records a high-level principle or course of action that has been decided on.
The intended purpose is to influence and guide both present and future decision making to be in line with the philosophy, objectives and strategic plans established by the enterprise’s management teams.
Overall intention and direction as formally expressed by management.
Any general statement of direction and purpose designed to promote the coordinated planning, practical acquisition, effective development, governance, security practices, or efficient use of information technology resources.
Intention and direction of an organization as formally expressed by its top management.
Statements, rules or assertions that specify the correct or expected behavior of an entity.
A statement of objectives, rules, practices or regulations governing the activities of people within a certain context.
NIST Glossary (Security Policy):
Note 1: System elements include technology, machine, and human, elements.
Note 2: Rules can be stated at very high levels (e.g., an organizational policy defines acceptable behavior of employees in performing their mission/business functions) or at very low levels (e.g., an operating system policy that defines acceptable behavior of executing processes and use of resources by those processes).
Security policies define the objectives and constraints for the security program. Policies are created at several levels, ranging from organization or corporate policy to specific operational constraints (e.g., remote access). In general, policies provide answers to the questions “what” and “why” without dealing with “how.” Policies are normally stated in terms that are technology-independent.
A set of rules that governs all aspects of security-relevant system and system element behavior.
Cybersecurity Control Objective
Control Objectives are targets or desired conditions to be met. These are statements describing what is to be achieved as a result of the organization implementing a control, which is what a Standard is intended to address. Where applicable, Control Objectives are directly linked to an industry-recognized secure practice to align cybersecurity and privacy with accepted practices. The intent is to establish sufficient evidence of due diligence and due care to withstand scrutiny.
A statement of the desired result or purpose to be achieved by implementing control procedures in a particular process.
Statement describing what is to be achieved as a result of implementing controls.
Standards are mandatory requirements regarding processes, actions and configurations that are designed to satisfy Control Objectives. Standards are intended to be granular and prescriptive to ensure systems, applications and processes are designed and operated to include appropriate cybersecurity and privacy protections.
A mandatory requirement.
Classification of components.
Specification of materials, performance, or operations; or
Delineation of procedures.
A published statement on a topic specifying the characteristics, usually measurable, that must be satisfied or achieved to comply with the standard.
A rule, condition, or requirement describing the following information for products, systems, services or practices:
Cybersecurity Guideline / Supplemental Guidance
Guidelines are recommended practices that are based on industry-recognized secure practices. Guidelines help augment Standards when discretion is permissible. Unlike Standards, Guidelines allow users to apply discretion or leeway in their interpretation, implementation, or use.
A description of a particular way of accomplishing something that is less prescriptive than a procedure.
Recommendations suggesting, but not requiring, practices that produce similar, but not identical, results.
A documented recommendation of how an organization should implement something.
Statements used to provide additional explanatory information for security controls or security control enhancements.
Controls are technical, administrative or physical safeguards. Controls are the nexus used to manage risks through preventing, detecting or lessening the ability of a particular threat from negatively impacting business processes. Controls directly map to standards, since control testing is designed to measure specific aspects of how standards are actually implemented.
The means of managing risk, including policies, procedures, guidelines, practices or organizational structures, which can be of an administrative, technical, management, or legal nature.
Controls include any process, policy, device, practice, or other actions which modify risk.
Controls may not always exert the intended or assumed modifying effect.
The policies, procedures, practices and organizational structures designed to provide reasonable assurance that business objectives will be achieved and undesired events will be prevented or detected and corrected.
Measure that is modifying risk:
Measure that is modifying risk. (Note: controls include any process, policy, device, practice, or other actions which modify risk.)
NIST SP 800-53 R5:
The safeguards or countermeasures prescribed for an information system or an organization to protect the confidentiality, integrity, and availability of the system and its information [security control].
The administrative, technical, and physical safeguards employed within an agency to ensure compliance with applicable privacy requirements and manage privacy risks [privacy control].
Procedures are a documented set of steps necessary to perform a specific task or process in conformance with an applicable standard. Procedures help address the question of how the organization actually operationalizes a policy, standard or control. Without documented procedures, there can be defendable evidence of due care practices. Procedures are generally the responsibility of the process owner / asset custodian to build and maintain but are expected to include stakeholder oversight to ensure applicable compliance requirements are addressed. The result of a procedure is intended to satisfy a specific control. Procedures are also commonly referred to as “control activities.”
A document containing a detailed description of the steps necessary to perform specific operations in conformance with applicable standards. Procedures are defined as part of processes.
A detailed description of the steps necessary to perform specific operations in conformance with applicable standards.
A group of instructions in a program designed to perform a specific set of operations.
A set of instructions used to describe a process or procedure that performs an explicit operation or explicit reaction to a given event.
Risks represents a potential exposure to danger, harm or loss.* Risk is associated with a control deficiency (e.g., If the control fails, what risk(s) is the organization exposed to?). Risk is often calculated by a formula of Threat x Vulnerability x Consequence in an attempt to quantify the potential magnitude of a risk instance occurring. While it is not possible to have a totally risk-free environment, it may be possible to manage risks by avoiding, reducing, transferring, or accepting the risks.
The combination of the probability of an event and its consequence.
The level of impact on organizational operations (including mission, functions, image, or reputation), organizational assets, individuals, other organizations, or the Nation resulting from the operation of an information system given the potential impact of a threat and the likelihood of that threat occurring.
NIST SP 800-53 R5:
The adverse impact, or magnitude of harm, that would arise if the circumstance or event occurs; and
The likelihood of occurrence.
A measure of the extent to which an entity is threatened by a potential circumstance or event, and typically is a function of:
The adverse impacts that would arise if the circumstance or event occurs; and
The likelihood of occurrence. Information system-related security risks are those risks that arise from the loss of confidentiality, integrity, or availability of information or information systems and reflect the potential adverse impacts to organizational operations (including mission, functions, image, or reputation), organizational assets, individuals, other organizations, and the Nation.
A measure of the extent to which an entity is threatened by a potential circumstance or event, and typically a function of:
Threats represents a person or thing likely to cause damage or danger. Natural and man-made threats affect control execution (e.g., if the threat materializes, will the control function as expected?). Threats exist in the natural world that can be localized, regional or worldwide (e.g., tornados, earthquakes, solar flares, etc.). Threats can also be manmade (e.g., hacking, riots, theft, terrorism, war, etc.).
Anything (e.g., object, substance, human) that is capable of acting against an asset in a manner that can result in harm.
A potential cause of an unwanted incident.
Threat: Any circumstance or event with the potential to adversely impact organizational operations (including mission, functions, image, or reputation), organizational assets, or individuals through an information system via unauthorized access, destruction, disclosure, modification of information, and/or denial of service. Also, the potential for a threatsource to successfully exploit a particular information system vulnerability.
Cyberthreat: Any circumstance or event with the potential to adversely impact organizational operations (including mission, functions, image, or reputation), organizational assets, individuals, other organizations, or the Nation through an information system via unauthorized access, destruction, disclosure, modification of information, and/or denial of service.
Metrics provide a “point in time” view of specific, discrete measurements, unlike trending and analytics that are derived by comparing a baseline of two or more measurements taken over a period of time. Analytics are generated from the analysis of metrics. Analytics are designed to facilitate decision-making, evaluate performance and improve accountability through the collection, analysis and reporting of relevant performance related data. Good metrics are those that are SMART (Specific, Measurable, Attainable, Repeatable, and Time-dependent).
A quantifiable entity that allows the measurement of the achievement of a process goal.
A thing that is measured and reported to help with the management of processes, services, or activities.
Tools designed to facilitate decision making and improve performance and accountability through collection, analysis, and reporting of relevant performance-related data.
Documentation Should Be Hierarchical: Policy > Standard > Procedure
In an effort to help clarify this concept, ComplianceForge Hierarchical Cybersecurity Governance Framework™(HCGF) takes a comprehensive view towards the necessary documentation components that are key to being able to demonstrate evidence of due diligence and due care. This framework addresses the interconnectivity of policies, control objectives, standards, guidelines, controls, risks, procedures & metrics. The Secure Controls Framework (SCF) fits into this model by providing the necessary cybersecurity and privacy controls an organization needs to implement to stay both secure and compliant.
ComplianceForge has simplified the concept of the hierarchical nature of cybersecurity and privacy documentation in the following downloadable diagram to demonstrate the unique nature of these components, as well as the dependencies that exist:
In the context of good cybersecurity & privacy documentation, policies, standards and procedures are key components that are intended to be hierarchical and build on each other to build a strong governance structure that utilizes an integrated approach to managing requirements. Your cybersecurity & data protection documentation is meant to address the “who, what, when, how & why” across the strategic, operational and tactical needs of your organization:
Assigning "Ownership" of Policies, Standards and Procedures
One of the most important things to keep in mind with procedures is that the "ownership" is different than that of policies and standards:
Policies, standards and controls are designed to be centrally-managed at the corporate level (e.g., governance, risk & compliance team, CISO, etc.)
Controls are assigned to stakeholders, based on applicable statutory, regulatory and contractual obligations
Procedures are by their very nature de-centralized, where control implementation at the control level is defined to explain how the control is addressed.
Given this approach to how documentation is structured, based on "ownership" of the documentation components:
Policies, standards and controls are expected to be published for anyone within the organization to have access to, since it applies organization-wide. This may be centrally-managed by a GRC/IRM platform or published as a PDF on a file share, since they are relatively static with infrequent changes.
Procedures are "living documents" that require frequent updates based on changes to technologies and staffing. Procedures are often documented in "team share" repositories, such as a wiki, SharePoint page, workflow management tool, etc.
Below is an example of how documentation can be broken down from a law/regulation/framework to build documentation (e.g., policies, standards, guidelines, procedures, etc.):
Frameworks are often referred to as a standard. In reality, most frameworks are merely a repository of specific controls that are organized by control families (e.g., NIST CSF, ISO 27002, NIST SP 800-171, NIST SP 800-53, etc.).
For example, while NIST SP 800-53 R5 is called a "standard" it is made up of 1,189 controls that are organized into 20 control families (e.g., Access Control (AC), Program Management (PM), etc.). These controls are what make up NIST SP 800-53 as a "framework" that an organization can use as a guide to develop its internal policies and standards that allow it to align with those expected practices.
Internal Security Documentation
An organization is expected to identify a framework that it wants to align its cybersecurity program with, so that its practices follow reasonably-expected controls.
Ideally, there should be a policy that corresponds to each of the control families. This helps make an organization's alignment with its adopted framework more straightforward.
Control objectives provide a 1-1 mapping to address a specific control (e.g., AC-3, AC-7, etc.). For each control objective:
There should be a granular standard that addresses the objective of the control (hence the name "control objective").
The standard may or may not have guidelines that accompany the standard.
There should be a Standardized Operating Procedure (SOP) that describes how the standard is operationalized to meet the intent of the control.
Questions? Please contact us for clarification so that we can help you find the right solution for your cybersecurity and privacy compliance needs.
Secure Controls Framework (SCF) "Premium Content" - Expertise-Class Policies, Control Objectives, Standards, Guidelines, Controls & Metrics.
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